Healthcare Provider Details

I. General information

NPI: 1053538975
Provider Name (Legal Business Name): CHARLES R SMITH C.M.H.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2007
Last Update Date: 12/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2909 WASHINGTON BLVD STE 101
OGDEN UT
84401-3773
US

IV. Provider business mailing address

PO BOX 6332
OGDEN UT
84402-6332
US

V. Phone/Fax

Practice location:
  • Phone: 888-801-1556
  • Fax:
Mailing address:
  • Phone: 888-801-1556
  • Fax: 877-544-4630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number7971378-6004
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number7971378-6004
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: